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Application For Permission To Work In The Entertainment Industry DLSE-277 - California
| Application For Permission To Work In The Entertainment Industry Form. This is a California form and can be used in DLSE Forms Workers Comp . |
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STATE OF CALIFORNIA Division of Labor Standards Enforcement THIS IS NOT A PERMIT NEW (never applied before) RENEW Permit No. ______________ APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY PROCEDURES FOR OBTAINING WORK PERMIT 1. Complete the information required below. 2. School authorities must complete the "School Record" section below for minors in grades 1 thru 12. 3. For minors 15 days through kindergarten, please attach a photo copy of minor's birth certificate. See reverse side for other documents that may be accepted. 4. All signatures MUST be in original ink. No fax or photo copies permitted. 5. Mail or present the completed application to any office of the Division of Labor Standards Enforcement for issuance of your work permit. Work permits will be issued within 3 business days and mailed to you. 6. Please provide a preaddressed, stamped envelope so the permit can be mailed back to you. Name of Child Permanent Address Number Street City State Zip Code Professional Name (if applicable) AKA: Home Phone Number School Attending Date of Birth Age Height ` " ft. in. Weight lbs. Hair Color Eye Color Grade Gender Male Female STATEMENT OF PARENT OR GUARDIAN: It is my desire that an Entertainment Work Permit be issued to the above named child. I will read the rules governing such employment and will cooperate to the best of my ability in safeguarding his or her educational, moral and physical interest. I hereby certify, under penalty of perjury, that the foregoing statements are true and correct. By submitting personal information about yourself and your minor child to DLSE in order to obtain an entertainment work permit for your child, you consent to DLSE's use of that personal information for purposes authorized by Labor Code § 1308.5 and 1308.10, which provide for the issuance of such permits. Note that DLSE's use of such personal information includes the disclosure of information about you and your minor child to third parties who want to verify a work permit. Name of Parent or Guardian (print or type) Signature Daytime Phone Number SCHOOL RECORD Circle whether "SATISFACTORY" or "UNSATISFACTORY" for each Attendance Academics (Grades) Health Please indicate if the minor requires medical approval to obtain a permit SATISFACTORY / NEEDS MEDICAL APPROVAL SATISFACTORY / UNSATISFACTORY SATISFACTORY / UNSATISFACTORY I CERTIFY THAT THE ABOVE-NAMED MINOR: Meets the school district's requirements with respect to age, school record, attendance and health. Does not meet the district's requirements and permit should not be issued. Authorized School Official, Signature and Title School Address Date School Phone Number [School Seal, Stamp, Address Stamp or Signed Letterhead] REQUIRED HEALTH RECORD Complete this Section if instructed to do so or if infant is under One Month of Age Name of Doctor Address Phone Number I certify that I am a licensed physician and surgeon who is Board Certified in pediatrics , and have carefully examined ___________________________ In my opinion, (please circle) he / she is / is not than one month, infant is / is not at least 15 days old, . Signature Remarks physically fit to be employed in the production of motion pictures and television. If less was / was not carried to full term, and is / is not physically able to perform. ____________________________________________________ M.D. Date ________________________ *PLEASE USE DOCTOR'S OFFICE STAMP ON APPLICATION TO ENSURE AUTHENTICITY.* DLSE- 277 (Rev. 03/12) Application for Permission to Work in Entertainment Industry English American LegalNet, Inc. www.FormsWorkFlow.com Information covering California's child labor laws applicable to the entertainment industry can be found at http://www.dir.ca.gov/dlse/DLSE-CL.htm. PROCEDURE FOR OBTAINING AN "ENTERTAINMENT PERMIT" NEW 1.) Application Form 2.) Parent/Guardian 3.) School Record Information Obtain from any of the Division of Labor Standards Enforcement offices or from the website: www.dir.ca.gov/dlse/DLSEform277.pdf Complete all requested information on the front of the application. Please print and sign your name in original ink. To be completely filled out by authorized school official in original ink for minors in grades 1 thru 12. A PREADDRESSED, STAMPED ENVELOPE MUST ACCOMPANY THE APPLICATION REQUIREMENTS FOR NON-SCHOOL AGE CHILDREN 1.) 2.) 3.) 4.) Certified Birth Certificate Baptismal Certificate Official letter from hospital where born Passport (15 days through kindergarten) A PHOTO COPY OF ONE OF THE FOLLOWING: Every infant under one month of age must have a certification from a licensed physician and surgeon who is Board Certified in pediatrics certifying that the infant is at least 15 days old, was carried to full term, and is physically able to endure the stresses of a television or movie set. REQUIREMENTS FOR SCHOOL AGE CHILDREN PUBLIC / PRIVATE SCHOOL, ON-LINE / VIRTUAL ACADEMY AND OUT OF STATE RESIDENTS: (Grades 1 through 12) · When school is IN session, the application must be completed and dated during the current school session by an authorized school official. · When school is NOT in session (i.e., school break, vacations, holidays), either the minor's recent report card or letter from the school principal on school letterhead indicating that the minor is "satisfactory" in all academic subjects, health and attendance is required. HOMESCHOOLED: · If minor is homeschooled, the application must be completed by the parent/guardian and attached to either a current private school affidavit, or written verification indicating that the minor is "satisfactory" in all academic subjects, health and attendance from either the local school district, county office of education or state board of education where the minor lives. RENEWAL 1.) 2.) 3.) 4.) 5.) Complete application form (all questions) Send a copy of the old permit with the application. Enclose a self addressed, stamped envelope for return. If school is not in session, see above instructions. If school is in session, have school official complete and sign the "school record" section of the application form for minors in grades 1 through 12. THERE IS NO FEE SOCIAL SECURITY NUMBER IS NOT REQUIRED APPLICATION CANNOT BE PROCESSED VIA FAX DEPARTMENT OF INDUSTRIAL RELATIONS Division of Labor Standards Enforcement DLSE- 277 (Rev. 03/12) Application for Permission to Work in Entertainment Industry English American LegalNet, Inc. www.FormsWorkFlow.com
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